Tag: #coronavirus

Covid is Not Over – and It Won’t EVER Be

As provinces across Canada begin to lift restrictions from the Covid pandemic, there is a plethora of opinions raging about this. Some physicians feel the restrictions are being lifted too slowly. Others feel that it is just right. In Ontario at least, the most outspoken group are the physicians who demand ongoing restrictions. They have taken to using #Covidisnotover on Twitter.

Obviously, when dealing with a once in a century pandemic that has truly decimated patients and health care workers alike, there are still going to be unknowns going forward. But personally speaking, I think we have to realize a couple of things. First, Covid is not over. Second, and most importantly, it never will be.

Is the flu over? Is HIV over? Heck, are measles and RSV over? The answer to all of those is no. The viruses are still around, they are still infecting people and are mutating all the time (that’s why we need an annual flu shot).

There are always a certain amount of these viruses in the ecosystem. Why would Covid be any different? We are not going to completely eradicate Covid.

Given this – the question becomes, what do we do as a society?

One option, and certainly one that is promoted by the #covidisnotover types, is to continue ongoing restrictions, for much longer. Be it mask mandates, enforced vaccine passports, or continued limits on indoor capacity, the message from them seems to be to keep imposing restrictions for……well, I couldn’t really find consensus on an end date.

The most common argument for continuing restrictions (in Ontario anyway) is the continued positive case load. There are more positive cases than ever before, so why should we stop restrictions now?

Well, the short version is that while it is absolutely true that our case load is higher now than in, say October of 2020, many other factors have changed. In October of 2020, there were no vaccines. There were no oral medications that could help treat those who were infected. Guidance on the fact that Covid is airborne was still (shockingly) lacking.

In comparison, in March of 2022 over 90% of the adult population of Ontario has two covid vaccines, and are well on the way to their third. Evidence is clear that the vaccines are remarkably effective at preventing serious complications of Covid. There is now a strong emphasis on good ventilation as a way to reduce the Covid burden. The government is providing funding for Hepa filters in schools and child care settings. A protocol for rolling out the new oral medications exists, and, like all things, supply of the medications will increase with time.

So to compare just case numbers from October 2020 to March 2022, quite frankly is just comparing apples to oranges. We need to take all these other factors into account.

The other common argument is essentially “Look at Denmark!“. Pro restriction types point to the fact that Denmark lifted all Covid restrictions on February 1st, 2022, and now seems to have an exploding number of cases and mortality. Graphs like the one below are designed to shock people into thinking there is a catastrophe in Denmark:

But the graph doesn’t tell the whole story, and in fact a much more nuanced approach requiring a deep dive into the data is needed. I was going to try but I can’t do a better job of it than Michael Petersen did in his twitter thread:

The short version is that because so many people have Covid now, we need to do a better job of determining who died because of a covid infection (usually a covid pneumonia) vs who died of other causes, but incidentally happened to have Covid at the same time. A better graph showing the Denmark situation (taken from Petersen’s thread) taking this into account is here:

Before people start jumping all over this, let me also point out that I am acutely aware that there is a significant spike in deaths in Denmark recently, even if not specifically caused by Covid. We clearly need to do a deeper dive into why there were excess deaths. But part of that deeper dive must include whether deaths were caused by the restrictions themselves (delayed care, depression and mental health issues leading to people just giving up etc). In essence, is the cure (restrictions) causing more harm than the disease (Covid)?

Look, lockdowns and restrictions were initially necessary. There is good evidence that they helped to blunt the course of Covid. But there is also evidence that they have harmed society as well. The economic impacts with record government deficits that will tax our great grand children are well known. However, there are also other health care impacts.

In Ontario, we have a back log of 20 million health care services, leaving many patients feeling forgotten. There are consequences to delayed care and I have seen that in my own practice, and expect to see much more in the coming year. Yes, those consequences sadly will include deaths.

All of this is before we even consider the collateral damage done to mental health especially in our pediatric population. As Dr. Jetelina points out in her excellent sub stack, there has been a world wide increase in paediatric mental health issues. A 24-31% rise in children presenting with mental health issues and a shocking 69-133% (depending on age group) increase in children presenting with suicidal thoughts to Emergency Departments.

What does all this mean?

My personal feeling is that while we cannot ignore Covid (it’s a bad disease) and we need to continue to encourage vaccinations (they work), we need to start looking at the health care system as a whole. Should we mask in high risk areas? Sure. But should we continue to isolate people socially and restrict interactions in a lower risk population, when that clearly causes other harms? I would argue no.

We have been making decisions for a long time based on Covid numbers alone. There are other illnesses and disease that are out there, many of which have been worsened by the restrictions Covid has forced on us. We need to start basing our health care decisions on what’s best for overall population health, not just Covid.

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Governments Should Listen to the Experts and Ease Covid Restrictions

It’s time.

For the past two years, the majority of Canadians have done their part to help combat the greatest health care crisis in a generation. We’ve dutifully worn masks, social distanced, gotten vaccinated and done our part to help protect others.

When the pandemic began (has it been two years already?), very little was known about Covid19 and still less was known about how to treat it. Public Health leaders did their best to provide guidance in an ever changing environment. They got some stuff wrong (remember how we were all initially told not to wear masks ?). But they got more stuff right (the lockdowns did help slow the spread of Covid19).

We all paid a terrible price to fight Covid. Job losses. Economic uncertainty. Decreased social interaction. Mental health impacts on ourselves and most troublingly our children. Delayed medical procedures. The list could go on forever.

Through it all however, was the hope that at some point the pandemic would either end, or change to a more manageable form and we could start to live more normal, if not completely normal lives. I submit that time has come.

In Ontario, we have almost 90% of residents over age 12 who have had two covid vaccines. This would be the number we were told was necessary to achieve herd immunity. I understand that most people need three shots. But the reality is that with Covid being a seasonal virus that seems to mutate regularly, we may need annual booster shots. Surely we won’t keep restrictions forever because we will likely need vaccines forever.

Additionally, we now have new promising medications to treat covid infections. An oral medication that is 90% effective in reducing hospitalizations has been approved by Health Canada, and early distribution to those at highest risk has already begun. I appreciate we need to ramp up production of the medication, and have more of it in stock, but at least we have viable treatment options.

It’s not just this old country doctor saying we need to ease restrictions more. Last week, Ontario’s Chief Medical officer of health himself stated that we needed to re-assess the proof of vaccination process. Canada’s Chief Public Health Officer, Dr. Theresa Tam admitted that we needed to get back to some normalcy. Despite the fact that British Columbia had some of the highest Covid related death tolls with the Omicron wave, even their provincial Health Officer, the excellent Dr. Bonnie Henry, signalled that restrictions would be easing.

I would note that throughout the pandemic, there have been calls for all of us to “listen to the experts” and follow their guidance. Well, they are all signalling that it’s time to change the approach and that it’s time to start lifting restrictions.

To be clear, the restrictions should not be lifted all at once. There should be a stepwise approach to lifting them, but that stepwise approach should be relatively rapid now.

The first thing to go should be the Vaccine Passports/Mandates. Before I go further let me be abundantly clear – I strongly urge everyone to get vaccinated (unless you are one of the one in 100,000 people who has a legitimate medical reason not to). The covid vaccines were incredibly effective against the alpha to delta variants of Covid. They are “just” really good against Omicron. However, with even Dr. Moore admitting that the vaccines will not stop transmission of the Omicron variant (but will drastically reduce your risk of getting critically ill from it) the passports/mandates make no sense anymore.

As an aside, my loyal readers (both of them) will remember that I wrote on July 30, 2021 that vaccine mandates were a bad idea and would “embolden hesitancy and create more fear and mistrust.” Look what’s happened. We now have our nation’s capital essentially under siege from a convoy of people who have been further emboldened by these coercive measures. Think there is enough trust there to come to an amicable solution? Particularly in light of Dr. Moore’s comments that transmissibility will not change if vaccinated?

This is in no way meant to support whatever the Ottawa convoy/protest/blockade is calling itself right now. They have frankly lost the moral high ground by not calling out the fringe few among them who are anti-semites, racists and just plain loons. They need to leave Ottawa and go home.

None of that, however, changes the fact that since you can get Omicron from a vaccinated person as well as from an unvaccinated person – there is no point to a vaccine passport. Get rid of it now.

Once that’s done, the next step should be to ensure our health care system goes back to full regular work and then some. We are already severely backlogged, and there is a whole lot of overtime needed to catch up on the delayed medical procedures.

Next (and in short order) capacity needs to be increased at restaurants/arenas/other indoor gatherings. We need to allow many of the businesses who have suffered terribly to start getting back on their feet.

The last step should be to remove mask mandates. Covid is airborne, and as such, masks provide a significant amount of protection. It will likely be a bit longer yet before we can say that Covid 19 is endemic (always circulating in the community at a stable level without fluctuating) as opposed to pandemic (essentially prevalent at a higher level with significant impacts on the health care system). So mask rules should be the last to go.

But make no mistake, the harms of all the other restrictive measures, whether on significantly delayed health care procedures, or enormous effects on government budgets and the economy now clearly outweigh the effects of continued restrictions.

It’s time to start lifting.

For those of you interested in such things I briefly spoke about Covid19 on CTV News and the link is below where I did mention vaccine passports had to go.

It’s Time to Open Up Nursing Home Capacity

Recently, I posted what I referred to as a controversial tweet about the need to open up nursing home beds that had been closed during the seemingly never ending Covid pandemic.

While there was not much “controversy” in twitter feed as a result of this, it did lead to some questions being asked during an interview I gave for CTV News.

While I certainly appreciate the professional nature of the reporter (the always adept Kraig Krause), the reality is that 30 second blurb on this topic, in an interview about all things COVID, can’t really do it justice. So let’s delve into this deeper.

It’s no secret that Ontario’s Nursing Homes were hit hard by the Covid pandemic. One nursing home in my region, Roberta Place in Barrie, was ravaged badly by the disease. I still grieve for all of the residents and families there, including those who survived as they likely continue to suffer some of the after effects of what transpired.

In the wake of these and other such stories, the Ontario government quite correctly limited the number of residents in ward beds at nursing homes. Many of Ontario’s nursing homes are very old buildings. The nursing home I’m honoured to be a medical director for has great ownership (private as it happens) and great staff, but the building itself if 52 years old and would not meet newer, more modern standards for nursing homes.

When my nursing home was built, having a ward bed (four residents to a room) was thought to be reasonable. Given that Covid is airborne (like most other respiratory illnesses!) the COVID19 Directive #3 (linked above) for nursing homes limited the number of residents to two per room. This made perfect medical sense at the time, and I certainly supported it then.

The reality however, is that health care is not limited to a single disease. We do have Covid of course, but we have a whole lot of other illnesses that we need to deal with. The Ontario Medical Association has estimated that a minimum of 16 million visits or procedures have been delayed as a result of the pandemic. We can’t keep delaying these. We need to address all the other health care issues that Ontarian’s have, and not just maintain sole focus on Covid.

Right now, I personally have two patients who are in hospital waiting for a nursing home bed. They are not acutely ill. They do not need aggressive medical treatment. They need a nursing home. But they can’t get one because of the massive shortage of nursing home beds. And while I strongly applaud the government for planning to build more beds, they won’t be here for 4-5 years.

At the nursing home I work at, normally 60 patients could be housed, but it’s now limited to 45 because of the rules implemented during the pandemic. I imagine it’s one of many nursing homes that has been limited. While opening up those closed beds (at all the homes) likely won’t be enough, it will help alleviate the stress on hospitals. This is particularly important given (as I write this) no one knows how bad the on coming Omicron wave will be.

But wait – are we not risking increased covid infections in the nursing homes by doing this? We would be increasing, for lack of a better phrase, population density in these homes. The answer is not as straightforward as one would think.

First we now know that three doses of the Covid19 vaccine provides the maximum amount of protection. Just about every resident of a nursing home has had three doses – as have staff. There will never, ever, ever be a vaccine (for any disease) that is 100% effective. But that fact that our most vulnerable patients have had three doses is incredibly reassuring.

Second, we would have to ensure that nursing homes have the funds to put in proper air purifiers (with Hepa Filters) in their facilities. I’m not asking for a complete re-vamp of the HVAC systems (that will take too long). But even small portable air purifiers will make a difference.

Third, we would need to ensure a rapid swab and immunization policy for staff and visitors of nursing homes to further reduce the risk of Covid entering a facility. Just tossing it out there but how about all staff get swabbed once a week regardless of vaccine status, and visitors twice a week?

Fourth, as one of the smartest people I know put it, a bed is just a piece of furniture. We have to ensure that the homes who are short on staff, now have the ability to hire extra staff to take care of the residents in these beds.

The health care system is a behemoth. It is also interdependent on all of its various parts working together. A shortage of nursing home beds, means more people in hospital waiting for nursing homes, which reduces the hospitals ability to provide acute care which leads to further backlogs and delays in medically necessary treatments.

We cannot make nursing homes 100% safe (we can’t make anything 100% safe). But re-opening currently closed nursing home beds in the safest possible manner, will be a small step in the right direction. It will also provide the hospitals with a little bit of extra capacity, should Omicron stress the system more.

Letter to the Staff of My Nursing Home

Note: The following is a letter I sent to all the staff of Bay Haven Seniors, a joint Retirement and Nursing Home. There has been rather a lot of variable information about the new Covid vaccines out there, and I wanted to address that up front. Some of this information may help you as well, so I’m copying it here.

To:  All Staff at Bay HavenFrom: Dr. M. S. Gandhi, Medical Director
Re: New Vaccines for COVID19


As I think all of you are now aware, Bay Haven has been fortunate to have our staff given the opportunity to immunize early with the new vaccines for COVID19.  There has been much written about the vaccines in print and on Social Media (unfortunately!!) .  I wanted to let you know about some information on the development of the vaccine, and why I do strongly encourage people to get the vaccine.


In “normal” times (remember those?), when a drug company thinks about whether it’s a good idea to develop a vaccine for a certain disease, there is a bit of convoluted process that has to happen first.  Some officious bureaucrat at the drug company does a cost analysis on how much it will cost to make the vaccine and how much profit could be made from it.  Then it goes to a regulatory body in the host country where some other pointy headed bureaucrat looks at how widespread the disease is and whether it’s worth while to approve a trial.  Then it goes back to the company where some lawyer reviews the cost/benefit ratio, whence it goes back to the officious bureaucrat and then back to the pointy headed one.  Amazingly enough (and I’m not kidding here) this process can take 2,3, even 5 years before a trial even begins.


This time, every body agreed right off the bat that it was good idea to have a vaccine for COVID19, and so the up to five years of paperwork was eliminated. Seriously, that bureaucratic bafflegab can take that long.


The next step after the paper work is done is for a vaccine to undergo three phases of trials.  It’s important to know that both the Pfizer and Moderna vaccines DID undergo all three phases of trials.  Given the catastrophic situation around COVID, the trials were done quickly, but they were fully completed.  The Pfizer trials had about 42,000 people (by the way about 35% were people of colour ).  The Moderna vaccine had over 30,000 people (also with 35% people of colour).  The trials were extremely successful (94-95% effectiveness).  

The main side effects are the same as you would get from just about every other vaccine (pain at the injection site, fatigue, muscle pain, joint pain, fever).  These side effects are rare and and if they occur, go away in a couple of days.


There has also been a lot of talk about the fact that these are the first vaccines to be developed using “mRNA” technology.  I appreciate that when people talk about genetics, it can cause many people to have second thoughts.  But, mRNA technology has been studied for something like 30 years now in the oncology field.  Additionally, mRNA cannot and will not affect your genes.  It’s your genes that make mRNA in your body.  Your mRNA can’t go backwards and affect your genes.  


In short mRNA vaccines are an efficient, safe process.  They actually herald a new era of vaccine development that promises rapid and effective prevention for new pandemics in the future.  This is a good thing.


I also want to address some concerns about side effects circulating on social media.  The first is with respect to Bell’s Palsy.  There were four people in the Pfizer trials who developed Bell’s Palsy (now recovered) after getting a dose of the vaccine.  This translates to a side effect rate of .01%.  However, the “background rate” for Bell’s Palsy is .03%.  Put another way, if we were to simply pick 40,000 people at random, and watch them for a year, we would expect 12 people to get Bell’s Palsy.  This is why health professionals don’t feel that Bell’s Palsy is related to the vaccines.


Second, there is some talk about anaphylactic reactions (which can happen with any vaccines).  With the Pfizer vaccine the concern is polyethylene glycol.  Moderna has this in their vaccine too, but it seems in a different manner.  There may be some concern about this for patients who have severe allergies (to the point that you carry an epi-pen).  The best recommendation I could give is that if, and only if, you allergies are so bad that you need an epi-pen, it would be reasonable to wait for the Moderna vaccine (which just got approved today).  We expect this vaccine to be available for distribution in February.  If you do not need an epi-pen, then you should get the Pfizer one as it is out already.


If you want additional material, there is a nice thread from one of Ontario’s leading infectious disease specialists here:
https://threader.app/thread/1338610832884854784


There’s also a great interview with one of Ontario’s leading allergists/immunologists here:
https://twitter.com/jkwan_md/status/1339344606555746305


Finally, I would like to thank all of you for all the hard work you have done this year.  2020 is a year that we will never forget, and I suspect a year that we are all anxious to give the boot too.  Yet despite the hardship, the challenges and the seemingly unending (bad) surprises, you have continued to keep the residents safe, clean and comfortable.  Providing this at the latter stages of peoples lives is the absolute minimum sign of respect we can show, and the staff have done that in spades this year.


Thank you again, and allow me to wish all of you a Merry Christmas and a Happy New Year!


Dr. M. S. Gandhi

Medical Director, Bay Haven

COVID19 and Nursing Homes

For those of you who don’t know, I am the Medical Director of Bay Haven Care Community, a combined retirement and nursing home. Below is a letter that I sent to the family members of all the residents of the nursing home, updating them with information about COVID19. Reproduced here so it can be shared if others wish to copy it.

Dear Family Members of Residents of Bay Haven,

As the Medical Director of Bay Haven, I wanted to write to all of you to update you on some important new information about COVID19.

As you are likely aware, Ontario is now firmly in the second wave of the seemingly never-ending COVID19 pandemic.  As I write this, 99 out of 626 nursing homes in Ontario are in outbreak from COVID19.  Thankfully, Bay Haven is not one of them.  I hope and pray that it will stay that it will stay that way, and that the other nursing homes get out of outbreak as soon as possible.

Our knowledge of the COVID19 virus has increased significantly over the past few months.  We still don’t know everything about it, nor do we have a cure, but we can be better prepared than we were in the past.

We now know that the virus is largely spread by what’s called “aerosolized” means.  That’s to say that it is expelled by your mouth when you breath/talk/sing and floats in the air for a large period of time, thus spreading to others.  This is why wearing a mask is so important.  All of our staff and visitors have been required to wear masks for many months, in addition to all the other screening that we do.

With this knowledge, it is becoming more and more apparent for the need for high quality ventilation and air purifiers, particularly those with HEPA filters.  While the physical plant at Bay Haven is quite old, I am extremely grateful that the management of Bay Haven invested in HEPA air purifiers for all the large common areas, even before Health Canada updated their website to indicate the risk of airborne spread.  I applaud their commitment to keeping residents safe.

Additionally, there has been much speculation about the benefits of Magnesium, Zinc and Vitamin D in fighting viruses.  To be candid, the evidence for Magnesium is not that great.  Magnesium may kill viruses “in-vitro” – that’s to say, in a petri dish in a lab – but more study is needed to see how it works in a human body.  But at least it’s not harmful.

There is actually decent evidence that Zinc can help fight off viral infections.  Taking 25 mg of Zinc daily is not harmful and has benefits.

There’s been evidence that Vitamin D can help fight viral infections for some years now. Recently however, a large clinical trial showed that people with low vitamin D levels were more likely to get COVID19.  It’s a very large trial, and the first one I am aware of where the benefits vitamin D were proven for one specific virus.

What can you do?

First, of course we ask that you abide by our visitor polices, that have been mandated by the Public Health Departments.  These policies are sometimes frustrating to follow, but they have been implemented to keep our residents safe.  We ask that you please help us keep your loved ones safe.

Second, if you wish to provide additional protection, you could purchase a small room HEPA air purifier for your loved one.  These would stay next to the head of the bed in the room, and provide additional protection.  Currently they range in price from about $60 to $90 from Amazon. There are other models as well, of course, but they should be HEPA certified to be effective.  At that price, frankly these devices will only last 6-9 months before going bad, but hopefully by that time we will have a vaccine. (While a vaccine is expected shortly, there are many distribution problems with them, and I don’t expect them to be available for a few months).

Finally, if you would like your loved ones to start Magnesium, Zinc and Vitamin D, please let me know by replying to this email, and I will ensure these are ordered. To be clear, this is “off label”- it’s not specifically an approved therapy, but it is at least very safe, and not harmful at standard doses.

None of these measures of course, is guaranteed to prevent a COVID infection, or an outbreak, but right now, represents the best possible protection we can provide.

I hope and pray you all continue to stay safe and well.

Your sincerely, 

Dr. M. S. Gandhi, MD, CCFP

Medical Director,

Bay Haven Seniors

We Need to Learn to Live With COVID-19

“All of this has happened before, and will happen again.” – Lt. Kara Thrace, aka Starbuck, from the Battlestar Galactica (2004) TV show.

An advantage of being old is that whatever is happening, you have likely seen it, or something like it before. Every so often, society undergoes an upheaval and people have to change behaviours. For those of us who were around in the 1980s, there are some stark parallels to what happened then, and what society must do now in 2020.

The early 1980s were a different time not only for how we lived as a society, but for how medicine was practiced. This was particularly true with how we handled body fluids. As surprising as it may be to some younger readers, there was no such thing as universal body fluid precautions back them. If you had a known blood born illness like hepatitis, then sure, extra precautions were taken. But not for every body. When I was in medical school, there were multiple stories of a particularly nasty vascular surgeon who would squirt blood on trainees during surgery if they got an answer wrong to his questions. Needle prick injuries were routinely ignored. There was not a robust sharps disposal system. In short, it was very different.

A huge shift in society, and medicine, came when reports of a novel virus (sound familiar?) became publicized. This virus was new, deadly, and little was know about it. At first, this strange new illness seemed to only affect gay men. This led to all sorts of additional discrimination against the gay community, and even more ostracization then they were already experiencing. Mainstream media outlets routinely referred to it as “The Gay Plague” which clearly didn’t help matters. This also led to whack job conspiracy theories about its origins, some of which persist to this day.

This strange new illness was, of course, eventually named “Acquired Immune Deficiency Syndrome” or AIDS and the virus that causes it was identified (Human Immunodeficiency Virus or HIV). It was recognized that body fluid transmission could spread it and that it was not limited by sexual orientation. We learned it was possible to carry the virus and not have symptoms and you could get it from anyone.

And so, the age of universal blood and body fluid precautions began, and policies around this were implemented in hospitals and other health facilities between 1985-1988.

But there was also a shift in how society responded. Until then, most public service announcements around Sexually Transmitted Disease (like this painfully dated one from 1969) focused simply on encouraging people to get treatment after the fact. And accepting that it was possible for you (yes, sweet innocent you) to get an STD.

AIDS changed all that. Suddenly, an STD could be deadly. Suddenly there was no cure or vaccine. Suddenly, just getting treatment wasn’t an option, and education around prevention was mandatory.

With education, the public took precautions. “No glove, no love” was a popular catchphrase used to promote latex condom use as these were proven to significantly reduce the risk of transmission of STDs (including HIV). Public service announcements shifted to openly talking about prevention.

In short, people and society adapted, and changed behaviours to deal with this new virus.

Today of course, we are faced with a novel new virus, that is clearly deadly and is widely publicized. Little was know about it at the start, and we continue to learn about it. The virus seems to have originated out of China, and this has led to all sorts of anti-Asian racism (including from the President of the United States). There are whack job conspiracy theories about it. As we learn more about the virus, we know asymptomatic spread is possible, and that, yet again, anyone can get it. There is no vaccine (and despite Dr. Fauci’s optimism I’m not holding my breath) and no effective cure.

In response, hospitals and other health facilities are implementing new polices around Personal Protective Equipment (PPE). Hospitals are taking extra precautions around elective surgery as the risk of mortality in patients who get COVID19 infections peri-operatively is ridiculously high. In my office I now see patients wearing a mask, eye protection, and surgical scrubs that I immediately remove after my day is done.

And now too, society will be asked to change in response to this most awful virus. The simplest thing to do of course, is to wear masks when you are in an indoor public place, or better yet whenever you leave the house. As mentioned in an earlier blog, one only has to look at Japan where there was poor social distancing, packed public transit and no closure of their famous karaoke bars, but people wore masks, and the number of infections was extremely low. Wearing them also is key to restarting the economy so we can get on with our lives.

Next, we need to accept contact tracing. Aggressive contact tracing in South Korea was largely responsible for their low rates of infection. I was glad to hear that Ontario will be introducing an app to do this. I can already hear the cries of invasion of privacy, but if we are to control this virus, we are going to have to figure out a way to contact trace safely, and protect personal privacy at the same time.

The big difference between the AIDS epidemic of the 1980s and COVID19 now is, of course, the economic costs. The economy was never shut down then, and the kind of wholesale level of job loss we are experiencing now in (hopefully) once in a life time.

But if we are to get the economy running (and we must for a whole bunch of reasons, including the fact a good job improves overall health care), then society will need to adapt again. We did it forty years ago, and I believe we can do it again.

I am however, not looking forward to 2060…….

Critical Decisions Looming for Health Care

The past three months have seen us undergo a stress like we’ve never seen before in our lives. People have lost their jobs, been socially isolated, and, importantly, non COVID healthcare has been delayed significantly. It’s estimated that 12,200 hospital procedures are delayed each week in Ontario alone. (Back of napkin math suggests 125,000 procedures have been delayed since the start of the pandemic).

In Ontario, these sacrifices have had the desired effect. The number of patients with serious complications from COVID has been trending down. Because we are not able to test everyone, I look at the number of patients who are in hospital due to COVID, and especially those who are on a ventilator, as an indication of how widespread the disease is. Because Canadians did what was necessary to protect others, our hospitals have not been as overwhelmed as many had feared.

The above image was taken from the Public Dashboard on COVID that the OMA staff put together and the link is in the paragraph above.

However, we are now facing another critical situation in healthcare. The complications that are arising in the people who had their healthcare delayed are reaching alarming proportions. Even at the best of times, our healthcare system was overburdened and overwhelmed. To add to all of that this additional backlog, and the fact that many of those patients have deteriorated and are sicker, and, well, you understand the dilemma we are facing.

I don’t have a degree in biostatistics, like current Ontario Medical Association (OMA) President Dr. Samantha Hill. I can’t crunch all the numbers and give you a statistically valid analysis of what we are facing. I can only speak to what I’m seeing in my own practice.

  1. a patient with significant stomach pain who had scans delayed for a month, only to discover cancer
  2. a patient who I diagnosed with melanoma, who still hasn’t gotten the required wide excision, and lymph node biopsy 8 weeks later
  3. a patient who sent me an email clearly indicating the desire to commit suicide because of the mental health effects of this pandemic (I got a hold of them and appropriate measures have been taken)
  4. a patient with a cough since January who still hasn’t seen a specialist
  5. a sharp increase in patients requesting counselling or medications for the stress and depression directly caused by the effects of the pandemic
  6. at least 5 patients who were already waiting for joint replacement surgery now delayed even more

Keep in mind that I am just one comprehensive care family in doctor in a province that has almost 10,000, and you get a sense of the scope of how much these delays are going to affect people.

This is why there is a real dilemma for those who make decisions about when and how to open up health care (and everything else). If we loosen restrictions, start opening the economy, and allow scenes such as what happened at Trinity Bellwood’s park, the number of patients with COVID will increase. But if we don’t, other people will die, or at least suffer life altering illnesses, from non-COVID related diseases.

In cold, unfeeling numbers, the worry by people like my esteemed colleague Dr. Irfan Dhalla is that we will accept between 10-40 deaths per day from COVID in Ontario. But the reality is that about 275 people a day die in Ontario from a myriad of causes (cancer, heart disease, stroke, suicide etc). What if the price of lowering the 10-40 numbers to zero, is to increase the 275 to 325? To be clear, I don’t know if we are at that point, and even more frankly, I doubt Ontario’s archaic health data systems could even help us figure it out. I just know that has to be a critical concern going forward.

So what can be done? The OMA has released a document on emerging from the lockdown, referred to as “The Five Pillars” paper. This is an excellent paper and it is worth reading. I would, however, add the following thoughts.

First, it’s obvious now, that wearing face masks going forward is essential. A look at Japan shows they did everything wrong, except wear masks, and they have one of the lowest COVID rates around. (And yes, I and others told people not wear masks before and in hindsight that information was wrong). This is particularly important to mitigate the expected second wave of COVID in the fall.

Second, we need to move procedures out of the hospitals where possible. Many procedures like colonoscopies, cataract surgeries, diagnostic imaging, minor surgeries and so on, can be done outside of hospitals. Ontario has an Independent Health Facilities Act which licences these premises and ensures that they follow a high level of standards. They tend to operate more efficiently than hospitals and can see more patients than hospitals (whole bunch of reasons why). Previous Ontario Health Minister, “Unilateral” Eric Hoskins stopped licensing them, and it’s a decision that desperately needs to be reversed.

Third, we need to get our health data collection done properly. In Ontario, the plan was to develop Ontario Health Teams (OHTs) throughout the province that would allow the different agencies that cared for a patient (hospital, home care, physicians etc) to co-ordinate care. As Drs. Tepper and Kaplan point out, “fighting this pandemic requires collaboration from every part of the system and the patient voice. That is the promise of OHT.” To do this properly requires seamless electronic integration of a patient’s health record, and this should also serve as the basis for collecting COVID data. A system like this could also aid with contact tracing if done properly.

For the sake of the health care of all Ontarians, we need to open up health care and the economy, and we need to do that sooner rather than later. With a little bit of vision and forward thinking, it’s possible to do this in a safe manner. Let’s hope that’s what we see in the next few weeks.

Better Contact Tracing Essential: Requires Improved Public Health Systems

Recently, I came across the following graph of the waves of the Spanish Flu in 1918-1919. I don’t know the exact source of this graph. However, the information on the graph lines up exactly with what the Centre for Disease Control (CDC) describes as the three waves of the Spanish Flu.

To be clear, nobody at this time knows if the same pattern will be followed by COVID19. We know that the flu tends to have decreased transmission in humid weather, but we don’t know if COVID19 (caused by a different virus) will follow that pattern. Or even if that will make a difference during the first season of a pandemic. There’s a nice video explaining that here.

However, should this pattern be followed by the COVID19, suffice it to say that we are all in for a very long road ahead.

So what can be done to reduce the intensity of the second and third waves (if they come)? Physical distancing of course is number one on the list. While many physicians (myself included) suggested not wearing masks in public initially, we know know that doing so will keep YOU from spreading COVID19 if you are a carrier. So wear a mask. Finally, we need a robust tracking and isolating system (aka Contact Tracing) for people who test positive for COVID19, which frustratingly, we don’t have right now.

Widespread testing for COVID19 along with Contact Tracing is what the four most successful governments in the world have done to control the spread of COVID19. We need to learn from these governments. But for now it is something that we seem to be unable to do in Ontario, and there are multiple reasons why.

Piecemeal Structure of Public Health Units (PHUs)

The first is the piecemeal structure of PHUs in Ontario. Now to be clear, PHUs are manned by terrific doctors and front line staff. I had the pleasure of meeting many of them during my term as President of the Ontario Medical Association and they are all excellent, hard working people. But the infrastructure of PHUs, from the point of view of this family doctor, leaves a lot to be desired.

By my count, there are about 40 Public Health Units across the Province. To a large extent, they work somewhat independently from each other and use different referral forms. My office has patients from patients in both the Grey Bruce and the Simcoe Muskoka health units, and while the staff in both units is excellent, it’s frankly annoying to have two different sets of forms to refer patients (and have two different formats of reports come in).

Worse, not all of the Public Health Units are on an electronic records (seriously, some use paper), and there is not one consistent electronic record for PHU’s across the Province. This only complicates the collection of data and the ability to Contact Trace.

Curiously enough, addressing the disjointed nature of the public health units was something that the current provincial government tried to address early in it’s mandate. Part of the initial plans were to reduce the number of PHUs and standardize the processes. This was supposed to result in savings of 25% in the PHU budgets. (NB – personally I can’t see that much in savings, I’m thinking closer to 10% would have been achieved).

Of course given what happened with the COVID19 pandemic, and the “two second sound bite” nature of our media reporting, the story has become “Doug Ford cut spending – we have a pandemic – solution – spend more”. It’s a nice simple argument. “Hey we spent more money, problem solved.”

However, just spending more on public health (and to be clear again – I support wise investments in public health), isn’t enough. There’s no sense in spending more on a disjointed system. What’s needed is to get all the PHU’s across the Province to integrate into one standard electronic system of record keeping, so that they can more efficiently and effectively contact trace.

More Wide Spread Testing for COVID19

Next of course, we still need more wide spread testing, and ideally we need something called “point of care” testing. Once again, the four countries I referenced earlier led the way in testing as many people as possible. So this needs doing as well.

APP for Contact Tracing

Finally, we really should authorize a provincial app for Contact Tracing. Alberta already has one. Alberta has taken many precautions to ensure that patient privacy is protected (app does not use GPS, has a randomized non-identifiable ID, erases data every 21 days etc). We could just use that one, or a more Ontario centric one like this excellent one developed by physicians . It has some what more features and ease of use but uses GPS. Better yet, why not link and App to a patient’s own health care portal like MyChart, which already integrates COVID19 test results?

As the New York Times pointed out, Contact Tracing is hard. However, we need to get on with it. Without effective Contact Tracing, we can’t mitigate against the potential second and third waves of this pandemic. Without mitigation, the economic and health disaster will continue and untold millions more will continue to suffer.

Here’s hoping that instead of just throwing money at a problem, governments of all levels invest smartly at the right tools (standardized PHUs, contact tracing APPs etc.) to deal with the COVID19 Pandemic. The alternative is too frightening to consider.